Vaccination, a cornerstone of meningitis prevention strategies, plays a critical role by:

1. Reducing infection rates – vaccines, such as those targeting Neisseria meningitidis and Streptococcus pneumoniae or Haemophilus influenzae, have been shown to significantly lower the incidence of bacterial meningitis.

2. Age-specific protection – vaccination programs are tailored to protect vulnerable age groups, such as children under 5 years old (e.g., Streptococcus pneumoniae) and adolescents (e.g., Neisseria meningitidis).

3. Preventing severe outcomes – vaccines help prevent severe complications and mortality associated with meningitis.

4. Booster vaccines – findings suggest the need for booster vaccines, to maintain immunity over time.

5. Public health impact – vaccination programs contribute to broader public health goals by reducing disease burden, improving quality of life, and lowering healthcare costs. ​ ​

Romania’s free vaccination schedule (NIP) includes the pneumococcal conjugate vaccine (PCV13) for infants at 2, 4 and 11 months of age. Pneumococcus is a major cause of meningitis (among other invasive diseases)⁽⁴⁾. But, importantly, no meningococcal vaccine (i.e., vaccine against Neisseria meningitidis) is currently part of the mandatory NIP schedule⁽⁵⁾.

Vaccines against meningococcal disease are available in Romania on an optional basis. These include meningococcal serogroups ACWY (MenACWY) vaccine and meningococcal serogroup B (MenB) vaccine. These optional vaccines must generally be purchased privately (or by non-NIP providers). For the optional meningococcal vaccines, the coverage is low: approximately 9.9% for MenACWY among children whose parents opted for that vaccine and approximately 6.9% for MenB in the same optional-vaccine context⁽⁴⁾. Other challenges reducing coverage include misinformation/vaccine hesitancy⁽⁹⁾, logistical barriers, especially in rural/less-accessible regions (distance to clinics, fewer reminders etc.)⁽¹⁰⁾, and the cost of vaccines outside the free program, for parents who pay⁽⁴⁾.

Socioeconomic status (SES) has a significant influence on the risk, severity and outcomes of meningitis in children. The relationship is shaped by multiple social, environmental and healthcare-related factors.

1. Risk of infection

• Overcrowding and housing conditions: children from low-income families are more likely to live in crowded homes or communities, which increases the spread of meningococcal and pneumococcal bacteria.
• Nutritional status: malnutrition weakens the immune defenses, making children more susceptible to severe infections.
• Access to clean water and sanitation: poor sanitation increases exposure to pathogens, contributing indirectly to meningitis through other infections that can predispose to it (like ear infections or pneumonia).

2. Vaccination access and coverage

• Cost and availability: families with lower SES may have reduced access to vaccines if not fully covered by public health systems.
• Awareness and health literacy: lower parental education levels can lead to less awareness of meningitis symptoms, vaccine schedules, and the urgency of seeking care.

3. Healthcare access

• Delayed treatment: low SES can limit access to hospitals, doctors or antibiotics, leading to delayed diagnosis and worse outcomes.
• Geographic disparities: rural or underserved areas often have fewer pediatric care facilities, making timely intervention less likely.

4. Outcomes and prognosis

• Mortality: children from disadvantaged backgrounds often have higher mortality rates from meningitis because of late presentation, malnutrition, and limited intensive care access.
• Long-term complications: survivors of meningitis (e.g., with hearing loss, neurological disability) may face additional challenges if families cannot afford rehabilitation, hearing aids, or special education.

There are documents stating that experts suggest starting meningococcal vaccination in early infancy (the first six months) with both MenB and MenACWY vaccines, at approximately 8 weeks of age⁽⁶⁾. They also recommend meningococcal vaccination for adolescents and young adults, especially those in risk situations (boarding schools, institutions, travel, healthcare settings). The recommendations include using booster doses for those over the age of 10 who remain at high risk. Importantly, the same recommendation paper advocates for the introduction of free-of-charge vaccination for risk groups, reimbursement of meningococcal vaccines, and establishing outbreak management regulations for invasive meningococcal disease (IMD)⁽⁶⁾.

There is a cost-effectiveness analysis for upgrading the pneumococcal vaccine in Romania (PCV20 versus PCV13/PCV15), showing that using PCV20 would be both more effective and cost saving over 10 years⁽⁷⁾. Also, there is evidence that uptake of some vaccines is falling in Romania (for example, MMR, pneumococcal conjugate vaccine), especially in certain rural or marginalized areas. There is no clear national guideline currently mandating that healthcare workers receive meningococcal vaccine. In a 2014 study, healthcare workers indicated the lack of clear recommendation for meningococcus vaccination among their requirements⁽⁸⁾.

From the experience of diagnosed and hospitalized cases at the “Sf. Parascheva” Clinical Hospital for Infectious Diseases, in Iaşi, Romania, between 2023 and 2025, a total of 157 patients were hospitalized, both adults and pediatric patients (74 patients in 2023, 47 in 2024, and 36 until July 2025) – Figures 1a and 1b.

The etiology of these cases was predominantly viral, even though in many instances it was not possible to identify the involved virus. We observe that bacterial etiology, especially meningococcal, was proven in approximately 5% of cases, but without considering the possible meningococcal etiology of cases with unspecified bacterial involvement (where Meningococcus was not isolated from the cerebrospinal fluid). Other bacterial etiologies included pneumococcal, staphylococcal and streptococcal meningitis, but with subunitary percentage values (Figures 1a and 2).

Regarding the distribution of cases based on the environment of origin, there is a slight predominance of cases from the rural environment (with the exception of cases diagnosed in the year 2023) – Figure 3.

The distribution of patients by gender shows a slightly higher percentage for the male gender (57.96%) compared to the female gender (42.06%) – Figure 4.

Pediatric patients and those aged up to 24 years old accounted for 42.03% (66 cases out of the 157 recorded). The age groups they fell into reveal a significantly higher proportion of patients of school age, preschool age and adolescents (5-14 years old), compared to cases recorded under 5 years old or over 14 years old (Figure 5).

As of the current year, up until July, we observe cases of meningococcal meningitis in all age groups processed statistically, without neglecting the equally frequent viral etiology. The age group of 5-14 years old is also the one with the highest proportion of patients (Figure 6).

Given the data presented before, it is mandatory to enhance all decision factors in providing population immunization against meningitis. Vaccination programs can be improved based on the findings in the following ways:

1. Targeted booster vaccines – studies suggest an increasing turn point while introducing a booster vaccine for meningitis and encephalitis that could enhance protection⁽¹⁾.

2. Age-specific vaccination strategies – studies highlight age-related differences in pathogen prevalence. For example, Streptococcus pneumoniae is more common in children under 5 years old, Neisseria meningitidis in children aged 5-18 years old, and Staphylococcus aureus in adults. Thus, vaccination programs can be tailored to target these age groups effectively.

3. Regional and seasonal adjustments – pathogen prevalence varies geographically and seasonally. Vaccination campaigns can be optimized to address these variations, ensuring better coverage in high-risk areas and during peak seasons.

4. Inclusion of meningitis B vaccination – pre­vious studies have demonstrated the benefit of meningitis B vaccinations in preventing Neisseria meningitidis infections. Expanding national vaccination programs to include meningitis B vaccines could further reduce infection rates.

5. Improved surveillance and monitoring – surveillance testing can help monitor antimicrobial resistance patterns and detect emerging pathogens early. This data can guide updates to vaccination programs to address evolving threats. 

We also identified gaps in vaccine efficiency that need to be filled with further studies.

• Current incidence of meningococcal disease in Romania. We need recent epidemiological surveillance data: number of cases per year, by age group, serogroups involved, case fatality rate, etc. This is essential to estimate burden and to perform cost-effectiveness analyses.
• Cost and budget implications. What is the cost per dose of MenB, MenACWY in Romania (procurement, distribution, administration)? How many would need to be vaccinated? What infrastructure would need strengthening?
• Cost-effectiveness in Romanian context. Modeling studies would be needed to simulate adding meningococcal vaccines to NIP: projected reduction in cases, hospitalization, long-term sequelae, economic cost savings versus the cost of vaccination in the specific health system and demographic structure of Romania.
• Public health readiness and equity. How acceptable are these vaccines to the public? What is the vaccine hesitancy? How well would rural or low-income populations be reached? What is the capacity to monitor safety, manage vaccine delivery logistics, etc.?
• Policy decision by the Ministry of Health. Could there be a formal law or it being considered to include free MenB /MenACWY vaccination in the national schedule?

There should be a constant need for improving vaccination schedule to also include meningitis vaccination in Romania, as well as reports regarding epidemiology and immunization, achieving cost-efficiency and reducing the burden of the disease in pediatric population.

Autor corespondent: Alice-Nicoleta Grudnicki E-mail: agrudnicki@yahoo.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.